Alcohol-Related Hepatitis

Severe alcohol-related hepatitis (AH) is associated with an at least one-in-twenty 28-day mortality, increasing to about 25% mortality at 3-12 months. Liver failure (either from primary liver injury or secondary causes such as infection or multi-organ injury), drives short-term mortality in AH, while after six months mortality is affected predominantly by abstinence.  

Diagnostically, it is important to exclude other causes of liver disease that may mimic AH such as drug-induced liver injury, flare of hepatitis B or auto-immune hepatitis or decompensated cirrhosis. Prognosis of AH can be estimated using scoring systems such as Maddrey’s Discriminant Function and Model for End-stage Liver Disease (MELD) score. 

Therapeutic options for AH have been disappointing. Nutritional supplementation has not shown to improve survival in randomised studies. Currently, there is no definitive evidence supporting pharmaco-therapeutic intervention with prednisone, pentoxifylline or other treatments that improve three-month or one-year mortality, and there is a risk of some harm, predominantly from sepsis. Abstinence remains the key predictor of long-term survival in alcohol-related hepatitis.  

A major survival gap remains for patients at risk of early mortality from alcohol-related hepatitis, with a high chance of death before six months of abstinence can be achieved, when liver transplant eligibility has traditionally been a limiting criterion. While the six-month abstinence rule is currently a preclusion to liver transplantation for severe alcohol-related hepatitis in Australia, new data has recently challenged this paradigm with reasonable short-term outcomes in this group of carefully selected patients. A global shift is evident with research in the process towards better identifying and characterising those patients with AH for whom liver transplantation is beneficial, safe and offers long term survival benefit.